COVID-19: ENT service guide

April 2020

Scope

This information provides guidance on the management of ENT patients in Torbay catchment area during the Covid-19 pandemic. The information is based on national guidance.

National guidance:

ENT surgeons are exceptionally vulnerable during the current pandemic due to the potential for aerosol generation during examination of the upper aerodigestive tract, and the extremely high viral load in upper airway mucosa.

ENT departments are often small in terms of medical staffing, and currently there is an urgent demand for healthy uninfected skilled ENT staff to provide critical services in the current crisis.

The purpose of these guidelines is to minimise risk to patients and staff via changes in practice to reduce the potential for viral spread during the current pandemic. The department aims to continue to provide the highest quality of care to patients with urgent clinical need whilst minimising the risk to healthcare practitioners and conserving critical resources.

2WW referrals

Will continue to be seen as an urgent priority.

Patients will be reviewed by a consultant in devoted head neck clinic slots on the daily emergency clinic - they will be telephone-screened using an ENT-UK approved risk calculator, and those needing face to face examination and further investigations will be seen in clinic by a senior clinician, and discussed by the Multidisciplinary Team where appropriate.

Conditions with specific guidance

Otology

Sudden sensorineural hearing loss (SSNHL)

ENT UK's guidelines advise against the use of oral steroids to treat SSNHL during the pandemic.

The use of intratympanic steroids is cautiously approved, but the relative risks need to be discussed with the patient first, so all SSNHL patients will need to be referred so that discussion can take place.

Facial Nerve Palsy

The presence of obvious ear or parotid disease in the context of lower-motor-neurone facial nerve palsy should lead to urgent referral for assessment. Routine prescription of oral steroids should be reserved for low risk patients with no comorbidities and profound idiopathic (grade V/VI) facial palsy. Herpes Zoster oticus may be treated with Valciclovir 3g/day and Prednisolone (.5mg/kg) for 1 week, with specialist referral for failure of resolution.

Menieres Disease

Severe exacerbations may be treated with SERC, buccastem, Bendrofluamethazide and low dose Diazepam. Uncontrolled debilitating disease may be referred for consideration of Intratympanic steroids.

Otitis externa

See advice & guidance sheet re water precautions & mopping

Rhinology

There is a very high viral load in the nasal mucosa, and any examination other than anterior rhinoscopy is highly likely to lead to aerosol generation and should be avoided where possible.

Anosmia

Numerous anecdotal reports suggest anosmia/dysgeusia as an early presenting symptom of SARS-Com2 in otherwise apparently healthy patients. Any instrumentation of the nose and blind prescription of oral steroids should be avoided, and the patients instructed to self-isolate for a week.

Chronic Rhinosinusitis

Very limited data suggests that systemic steroids increased the risk of ARDS in historical SARS/MERS cases, so any introduction of these agents as a treatment should only be after careful consideration. On the other hand, there is no data to suggest intranasal corticosteroids (INCS) increase virus susceptibility. The cessation of topical steroid use may cause confusion with respect to the symptoms of coronavirus infection, so INCS use should not be discontinued.

There has been suggestion that nasal douching may facilitate viral spread due to aerosol generation. Thorough handwashing before and after douching, frequent sterilisation of the apparatus and performance in a private area used only by the patient is recommended.

Epistaxis

Local anaesthetic sprays and attempts at cautery are aerosol-generating and should be avoided in primary care without adequate PPE.

Conservative first aid measures are important:-adequate anterior compression, sit upright, ice in mouth.

Blood pressure management and anticoagulant use should be optimised. Attempt conservative management with Naseptin/Bactroban nasal tds alternate days, using Vaseline as emollient.

Nasal Fracture

Nasal trauma in the absence of septal haematoma/septal abscess should be treated conservatively.

Sinus Surgery/Functional nasal surgery

These procedures are highly aerosol-generating and will not be carried out during the current pandemic.

Paediatrics

Tonsillectomy

Consider referral if SIGN criteria are met (i.e. 7 or more significant sore throats (with impact to patient and family) in the preceding 12 months or 5 or more episodes in each of the preceding two years, or 3 or more in each of the preceding three years).

Telephone/video consultation will be carried out and listing for surgery as appropriate.

Surgery will be deferred unless there are urgent indications such as Sleep Apnoea leading to cardiopulmonary complications.

Foreign Bodies

Button batteries remain an absolute indication for urgent surgery, as do sharp ingested objects and absolute dysphagia. A softer history, with coughing fit after play with small object should lead to referral for radiological investigation.

Airway

Suspected croup should be managed expectantly with oral steroids if necessary, avoiding nebulisers where possible to reduce the risk of viral dissemination. Early discussion with relevant paediatric services is advised.

Infection

In order to avoid surgical intervention where possible acute mastoiditis, periorbital cellulitis and deep neck space infections will be treated conservatively with antibiotics in an ambulatory setting. Early referral for assessment will help avoid suppurative complications.

Audiology

Audiology – Newborn hearing screening (NHSP) This service is continuing which means babies who gain a 'no clear response' (NCR) will be referred to Audiology via the Newborn Hearing screening team. Currently bilateral NCR babies will be offered a diagnostic assessment. Unilateral NCR will receive a telephone call, letter and informed when the baby can be tested.

The following groups of babies must be referred directly to audiology as current practice but this should be done by Paediatric consultant or NHSP team:

  • Group 1. Microtia and external ear canal atresia.
  • Group 2. Neonatal bacterial meningitis or meningococcal septicaemia
  • Group 3. Babies with a PVP shunt
  • Group 4. Confirmed congenital cytomegalovirus (cCMV)

These babies will be offered a diagnostic test.

Urgent referrals

Will be triaged using telephone consultations. Many will be deemed as able to wait for several months, but the safety net will be a phone number for the patient in difficulty.

Audiology – Hearing aid repairs/ hearing aid losses impacting on ability to manage safely during crisis (paediatrics or adults). Patient can contact us directly, or anyone on their behalf: technical services – 01803 655125 to discuss either face to face appointment where absolutely required, postal repair service or drop in system.

Tinnitus – please ring 01803 655125 or refer via DRSS e-Referrals Tinnitus service

Routine referrals

When the situation allows we will conduct a Consultant-led telephone/ video consultation but specialist examination is key to most ENT practice which is high risk at present so will be delayed until after this crisis. The current situation is dynamic and rapidly evolving and practices and recommendations are likely to change on the basis of new data and guidelines from our professional bodies.

Audiology – Adult hearing loss and Tinnitus. Refer via DRSS. Audiologists will telephone triage where possible, complete half the assessment where possible and add to a waiting list for completion of diagnostic testing when appointments open up.

Audiology - Paediatric hearing loss. Refer via DRSS, but will not be seen until situation changes.

Urgent advice

We are still maintaining an emergency service via ENT registrar/ SHO on call.

Many patients may not be able to be examined due to the high aerosol infection risk present even in some asymptomatic patients.

Audiology urgent advice line please call 018053 655125

Advice & Guidance

There is a daily Lead Consultant for ENT available via the hospital switchboard for urgent Advice and Guidance: 0300 456 8000 (local rate) or 01803 614567

Covid 19 High risk patient advice

Please contact on call consultant in ENT via the hospital switchboard: 0300 456 8000 (local rate) or 01803 614567

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Last updated: 11-05-2020

 

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